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The American Academy of Pediatrics Oral Health Initiative. The American Academy of Pediatrics Oral Health Initiative. Wendy Nelson Manager Oral Health Initiative January 25, 2008. www.aap.org/oralhealth. View the training online at www.aap.org/oralhealth/cme . Outline.

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the american academy of pediatrics oral health initiative

The American Academy of Pediatrics Oral Health Initiative

The American Academy of Pediatrics Oral Health Initiative

Wendy Nelson

Manager Oral Health Initiative

January 25, 2008

www.aap.org/oralhealth

outline
Outline

This training includes the following sections:

  • Overview of Dental Caries and Early Childhood Caries
  • Pathophysiology of Caries Process
  • History: Determining Caries Risk
  • Physical: Oral Health Assessment
  • Anticipatory Guidance
  • Treatment and Referral
introduction
Introduction

This section addresses the following topics:

  • Child Health Professional’s Role in Promoting Oral Health
  • AAP Recommendations for an Oral Health Risk Assessment
  • Learning Objectives
child health professionals role in promoting oral health
Child Health Professionals’ Role in Promoting Oral Health
  • See children early and regularly.
  • Become experts in oral health prevention strategies.
  • Advocate for child health: Oral health is part of overall health!
aap recommendations for an oral health risk assessment
AAP Recommendations for an Oral Health Risk Assessment
  • Assess mothers’/caregiver’s oral health.
  • Assess oral health risk of infants and children.
  • Recognize signs and symptoms of caries.
  • Assess child’s exposure to fluoride.
  • Provide anticipatory guidance including oral hygiene instructions (brush/floss).
  • Make timely referral to a dental home.
learning objectives
Learning Objectives
  • Understand the role of the child health professional in assessing children’s oral health.
  • Understand the pathogenesis of caries.
  • Conduct an oral health risk assessment.
  • Identify prevention strategies.
  • Understand the need for establishing a dental home.
  • Provide appropriate oral health education to families.
overview of dental caries and early childhood caries
Overview of Dental Caries and Early Childhood Caries

This section addresses the following topics:

  • Prevalence of Dental Caries
  • Early Childhood Caries
  • Early Childhood Caries Can Lead to …
  • Consequences of Dental Caries
prevalence of dental caries
Prevalence of Dental Caries
  • 5 times more common than asthma
  • 7 times more common than hay fever

Caries Rate

  • 18% aged 2 to 4 years
  • 52% aged 6 to 8 years
  • 67% aged 12 to 17 years
early childhood caries
Early Childhood Caries

A severe, rapidly progressing form of tooth decay in infants and young children

Affects teeth that erupt first,

and are least protected by saliva

Initial lesions—white decalcification with beginning enamel breakdown

Late stage lesions—moderate to severe enamel and dentin destruction

early childhood caries can lead to
Early Childhood Caries Can Lead to…
  • Extreme pain
  • Spread of infection
  • Difficulty chewing, poor weight gain
  • Falling off the growth curve
  • Extensive and costly dental treatment
  • Risk of dental decay in adult teeth
  • Crooked bite (malocclusion)
consequences of dental caries
Consequences of Dental Caries
  • Missed school days
  • Impaired language development
  • Inability to concentrate in school
  • Reduced self-esteem
  • Possible facial cellulitis requiring hospitalization
  • Possible systemic illness for children with special health care needs
pathophysiology of caries process
Pathophysiology of Caries Process

This section addresses the following topics:

  • Factors Necessary for Caries
  • Tooth
  • Oral Flora
  • Oral Flora: Pathogenesis of Caries
  • Oral Flora: How Does Infection Occur?
  • Fluoride’s Influence on Oral Flora
  • Substrate: You Are What You Eat
  • Substrate: Environmental Influences
  • Not Just What You Eat, But How Often
oral flora
Oral Flora
  • Normal oral flora = billions of bacteria.
  • Intraoral bacterial colonization occurs before the eruption of the first tooth.
oral flora pathogenesis of caries
Oral Flora: Pathogenesis of Caries
  • An infectious process
  • Initiated by pathogenic bacteria—Streptococcus mutans and Streptococcus sobrinus
oral flora how does infection occur
Oral Flora: How Does Infection Occur?
  • Transmitted mainly from mother or primary caregiver to infant
  • Window of infectivity is first 2 years of life
  • Earlier child colonized, the higher the risk of caries
fluoride s influence on oral flora
Fluoride’s Influence on Oral Flora
  • Promotes remineralization of enamel, and may arrest or reverse early caries
  • Decreases enamel solubility
  • Inhibits the growth of cariogenic organisms, thus decreasing acid production
  • Concentrated in dental plaque
  • Primarily topical even when given systemically
substrate you are what you eat
Substrate: You Are What You Eat
  • Caries is promoted by carbohydrates, which break down to acid.
  • Acid causes demineralization of enamel.
  • Frequent snacking promotes acid attack.
  • Foods with complex carbohydrates (breads, cereals, pastas) are major sources of “hidden” sugars.
  • High sugar content in sodas is a source of these substrates.
substrate environmental influences
Substrate: Environmental Influences
  • Saliva inhibits bacterial growth.
  • Unremoved plaque promotes the caries process.

Red disclosing tablet reveals plaque

not just what you eat but how often
Not Just What You Eat, But How Often
  • Acids produced by bacteria after sugar intake persist for 20 to 40 minutes.
  • Frequency of sugar ingestion is more important than quantity.
breastfeeding
Breastfeeding
  • The AAP and AAPD strongly endorse breastfeeding.
  • Although breastmilk alone is not cariogenic, it may be when combined with other carbohydrate sources.
  • For frequent nighttime feedings with anything but water after tooth eruption, consider an early dental home referral.
history determining caries risk
History: Determining Caries Risk

This section addresses the following topics:

  • High-Risk Groups for Caries
  • Children With Special HealthCare Needs (CSHCN)
  • Common Issues Among Children With Special Health Care Needs
  • Socioeconomic Factors
  • Ethnocultural Factors
  • Fluoride Exposure
high risk groups for caries
High-Risk Groups for Caries
  • Children with special health care needs
  • Children from low socioeconomic and ethnocultural groups
  • Children with suboptimal exposure to topical or systemic fluoride
  • Children with poor dietary and feeding habits
  • Children whose caregivers and/or siblings have caries
  • Children with visible caries, white spots, plaque, or decay
children with special health care needs cshcn
Children With Special Health Care Needs(CSHCN)

Recommendations for Child Health Professionals:

  • Be aware of oral health problems or complications associated with medical conditions.
  • Monitor impact of oral medications and therapies.
  • Choose non–sugar-containing medicationsif given repeatedly or for chronic conditions.
  • Refer early for dental care (before or by age 1 year).
  • Emphasize preventive measures.

Damage caused by holding medications in mouth

common issues among children with special health care needs
Common Issues Among Children With Special Health Care Needs
  • Children with asthma and allergies are often on medications that dry salivary secretions, increasing risk of caries.
  • Children who are preterm or low birthweight have a much higher rate of enamel defects and are at increased risk of caries.
  • Children with congenital heart disease are at risk for systemic infection from untreated oral disease.
socioeconomic factors
Socioeconomic Factors

The rate of early childhood dental caries is near epidemic proportions in populations with low socioeconomic status.

  • No health insurance and/or dental insurance
  • Parental education level less than high school or GED
  • Families lacking usual source of dental care
  • Families living in rural areas
ethnocultural factors
Ethnocultural Factors
  • Increased rate of dental caries in certain ethnic groups
  • Diet/feeding practices and child-rearing techniques influenced by culture
physical oral health assessment
Physical: Oral Health Assessment

This section addresses the following topics:

  • Maternal Primary Caregiver Screening
  • Child Oral Health Assessment
  • Positioning Child for Oral Examination
  • Primary Teeth Eruption
  • What to Look For
  • Check for Normal Healthy Teeth
  • Check for Early Signs of Decay: White Spots
  • Check for Early Signs of Decay: Brown Spots
  • Check for Advanced/Severe Decay
  • AAPD Caries Risk Assessment Tool (CAT)
fluoride exposure
Fluoride Exposure
  • Determine fluoride exposure: systemic versus topical
  • Fluoridated water
    • 58% of total population
    • Optimal level is 0.7 to1.2 ppm
    • Significant state variability
    • CDC fluoridation map
maternal primary caregiver screening
Maternal/Primary Caregiver Screening
  • Assess mother’s/caregiver’s oral history.
  • Document involved quadrants.
  • Refer to dental home if untreated oral health disease.
child oral health assessment
Child Oral Health Assessment

Prepare for the Examination

  • Provide rationale.
  • Describe caregiver role.
  • Ensure adequate lighting.
  • Assemble necessary equipment.
positioning child for oral examination
Positioning Child for Oral Examination
  • Position the child in the caregiver’s lap facing the caregiver.
  • Sit with knees touching the knees of caregiver.
  • Lower the child’s head onto your lap.
  • Lift the lip to inspect the teeth and soft tissue.
what to look for
What to Look For
  • Lift the lip to inspect soft tissue and teeth.
  • Assess for

- Presence of plaque

- Presence of white spots or dental decay

- Presence of tooth defects (enamel)

- Presence of dental crowding

  • Provide education on brushing and diet during examination.
aapd caries risk assessment tool cat
AAPD Caries Risk Assessment Tool (CAT)

Caries Risk Indicators

This chart was adapted (with permission) from a similar chart developed by the American Academy of Pediatric Dentistry. For more information on using this type of tool, refer tohttp://www.aapd.org/foundation/pdfs/cat.pdf and http://www.aapd.org/media/policies_guidelines/p_cariesriskassess.pdf.

anticipatory guidance
Anticipatory Guidance

This section addresses the following topics:

  • Anticipatory Guidance
  • Minimize Risk for Infection
  • Xylitol for Mothers
  • Substrate: Contributing Dietary and Feeding Habits
  • Toothbrushing Recommendations
  • Toothpaste and Children
  • Toothpaste
  • Optimizing Oral Hygiene: Flossing
minimize risk for infection
Minimize Risk for Infection
  • Address active oral health disease in mother/caregiver.
  • Educate mother/caregiver about the mechanism of cariogenic bacteria transmission.
  • Mother/caregiver should model positive oral hygiene behaviors for their children.
  • Recommend xylitol gum to mothers/caregiver.
anticipatory guidance1
Anticipatory Guidance
  • Minimize risk of infection.
  • Optimize oral hygiene.
  • Reduce dietary sugars.
  • Remove existing dental decay.
  • Administer fluorides judiciously.
xylitol for mothers
Xylitol for Mothers

Xylitol gum or mints used 4 times a day may prevent

transmission of cariogenic bacteria to infants.

  • Helps reduce the development of dental caries
  • A “sugar” that bacteria can’t use easily
  • Resists fermentation by mouth bacteria
  • Reduces plaque formation
  • Increases salivary flow to aid in the repair of damaged tooth enamel
substrate contributing dietary and feeding habits
Substrate: Contributing Dietary and Feeding Habits
  • Frequent consumption of carbohydrates, especially sippy cups/bottles with fruit juice, soft drinks, powdered sweetened drinks, formula, or milk
  • Sticky foods like raisins/fruit leather (roll-ups), and hard candies
  • Bottles at bedtime or nap time not containing water
  • Dipping pacifier in sugary substances
toothpaste and children
Toothpaste and Children
  • Children ingest substantial amounts of toothpaste because of immature swallowing reflex.
  • Early use of fluoride toothpaste may be associated with increased risk of fluorosis.
  • Once permanent teeth have mineralized (around 6-8 years of age), dental fluorosis is no longer a concern.
toothpaste
Toothpaste

A small pea-sized amount of toothpaste weighs 0.4 mg to 0.6 mg fluoride, which is equal to the daily recommended intake for children younger than 2 years.

optimizing oral hygiene flossing
Optimizing Oral Hygiene: Flossing

When to Use Floss

  • Once a day (preferably at night)
  • Whenever any 2 teeth touch
treatment and referral
Treatment and Referral

This section addresses the following topics:

  • Recommended Fluoride Supplement Schedule
  • Example of Fluorosis
  • Fluoride Varnish
  • Applying Fluoride Varnish
  • Remove Existing Dental Decay: Treating an Infection
  • Referral: Establishment of Dental Home
  • Community Systems of Care
recommended fluoride supplement schedule

Fluoride Concentration in Community Drinking Water

Age

<0.3 ppm

0.3–0.6 ppm

>0.6 ppm

0–6 months

None

None

None

6 mo–3 yrs

0.25 mg/day

None

None

3 yrs–6 yrs

0.50 mg/day

0.25 mg/day

None

6 yrs–16 yrs

1.0 mg/day

0.50 mg/day

None

Recommended Fluoride Supplement Schedule

MMWR: Recommendations for Using Fluoride to Prevent and Control Dental Caries in the US: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm.

example of fluorosis
Example of Fluorosis

Mild Fluorosis

Severe Fluorosis

fluoride varnish
Fluoride Varnish
  • 5% sodium fluoride or 2.26% fluoride in a viscous resinous base in an alcoholic suspension with flavoring agent (eg, bubble gum)
  • Has not been associated with fluorosis
  • Application does not replace the dental home nor is it equivalent to comprehensive dental care
referral establishment of dental home
Referral: Establishment of Dental Home

What is a dental home?

When to refer?

  • Refer high-risk children by 6 months.
  • Refer all children by 1 year.
community systems of care
Community Systems of Care
  • Identify dental care professionals in your community.
  • Develop partnerships.
conclusion
Conclusion

This section addresses the following topics:

  • You Can Make a Difference!
  • CME Credit
you can make a difference
You Can Make a Difference!
  • Institute oral health risk assessments into well-child visits.
  • Provide patient education regarding oral health.
  • Provide appropriate prevention interventions (eg, feeding practices, hygiene).
  • Document findings and follow-up.
  • Train office staff in oral health assessment.
  • Identify dentists (pediatric/general) in your area who accept new patients/Medicaid patients.
  • Take a dentist to lunch to establish a referral relationship.
  • Investigate fluoride content in area water supply.
cme credit
CME Credit

Take this training online to earnContinuing Medical Education credit!http://www.aap.org/oralhealth/cmeQuestions about this training?E-mail oralhealthinfo@aap.org.

photo credits
Photo Credits

Special thanks to the following individuals and

organizations for contributing to this training:

AAP Breastfeeding Initiatives

American Academy of Pediatric Dentistry

American Dental Association

ANZ Photography

Suzanne Boulter, MD

George Brenneman, MD

Content Visionary

Melinda Clark, MD

Joanna Douglass, BDS, DDS

Rani Gereige, MD

Donald Greiner, DDS, MSc

Indian Health ServiceMartha Ann Keels, DDS

Sunnah Kim

Cynthia Neal, DDS

Rama Oskouian, DMD

P&G Dental ResourceNet

Michael San Filippo

Gregory Whelan, DDS

credits
Credits

Primary Authors

Suzanne Boulter, MD, FAAP

Paula Duncan, MD, FAAP

Kevin Hale, DDS

Martha Ann Keels, DDS, PhD

David Krol, MD, MPH, FAAP

Wendy Mouradian, MD, MS, FAAP

Wendy Nelson, ACCE

Additional Contributors

Betty Crase, IBCLC, RLC

Martin J Davis, DDS

Adriana Segura Donly, DDS, MS

Rocio B Quinonez, DMD, MS, MPH

Kathleen Marinelli, MD, IBCLC, FAAP

Special thanks to the following individuals for contributing to the development of this training: